Numerous complaints have been lodged against TPAs who set their own fees and rules to be followed by doctors.

Managed care organisations (MCOs) and third party payers (TPPs) have been playing the role of ‘middlemen’ for the delivery of healthcare services for about 22 years now. The Medical Practitioners Coalition Association of Malaysia (MPCAM) called for the Malaysian Medical Council to review the ethical code and include guidelines for third party associations.

Representatives of the MPCAM, Dr Peter Chan and Dr Raj Kumar recommended numerous issues to be addressed in accordance with the regulations such as “patients’ inconsistent expectations, kickbacks and fee splitting, limitations on doctors, incentives for cost-cutting, patients’ lack of choice and doctors begging for payments.”

Employers and patients incurring higher costs

Dr Steven Chow, president of the Federation of Private Medical Practitioners’ Associations Malaysia (FPMPA) said there had been many instances of MCOs and TPPs closing down and leaving behind millions of ringgit in unpaid medical bills owed to doctors. “Experience over the past 20 years has shown that the MCO’s business model is that of cost control, not cost containment,” he added.

“It imposes rationing, exclusions and access to choice in order to control cost so as to increase their profit margin, much to the detriment of patient care. The end result is to pay for the middlemen services, resulting in higher cost to the employers and patients, and ultimately the rakyat – instead of reducing costs. The patient ends up paying more money for less care,” continued Dr Chow.

He concluded that “In simple terms, for the patient to see a doctor, he has to go through an appointed middleman and for a doctor to see a patient, he has to go through a middleman as well.”

Health ministry will potentially regulate third-parties

This comes after Health Minister Dr Subramaniam said in April that the ministry would study possibilities to regulate MCOs and TPAs under the provisions in the Private Healthcare Facilities and Services Act 1998. Numerous complaints have been lodged against TPAs who manage the health benefits of employees and implemented their own set of fees and rules to be abided by doctors.

Dr Subramaniam also stated that, currently, the health ministry does not monitor the issue since TPAs and MCOs are not under its purview and the service offered by them is a contract between doctors and the said entities.

Dr Chow noted that middlemen had the inherent right to approve or disapprove the payment for care and that distresses patients and doctors. He also stated that the FPMPA supported the need for stringent regulations under the Private Healthcare Facilities & Services Act (PHFSA) 1998 and Regulations 2006 to protect patients from middlemen.

“The patients and their doctors have been waiting for these regulations for more than 10 years. Doctors feel that their patients must be empowered to choose their provider and option of essential medical care without undue influence from third parties like the middlemen,” added Dr Chow. MIMS